Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute psychotic episode

1st line – start or review oral antipsychotic treatment

Back
ACUTE
|
acute psychotic episode
1st line – 

start or review oral antipsychotic treatment

An acute psychotic episode may be the first psychotic episode or it may occur in the setting of psychotic decompensation or resistance to antipsychotic medication.

The patient needs to be in a safe and predictable environment, and hospitalization is often needed.

If the acute episode is the first presentation, the patient needs to be established on antipsychotic medication. Such patients are usually naïve to antipsychotic agents and should be started on low doses and the dose titrated according to response.[47] Particular attention should be paid to adverse effects of the medication.

In a first acute psychotic episode, clozapine and olanzapine are not recommended. Clozapine may be recommended for patients with multiple episode disorder who fail at least two adequate trials of two different antipsychotic agents.

A trial of clozapine should last a minimum of 8 weeks.[47]

Routine checking of serum clozapine levels is not recommended; however, for clozapine non-responders it is recommended that the dose be increased, adverse effects permitting, for a target level >350 nanograms/mL.

Clozapine is available only under a restricted access scheme in the US and many other countries. White blood cell count and absolute neutrophil count should be tested periodically, owing to the risk of potentially life-threatening agranulocytosis.

If the acute episode is due to psychotic decompensation or to antipsychotic resistance, the medication dose often needs to be increased or a new antipsychotic medication started. If the patient has previously responded to a specific agent and the acute episode is a result of noncompliance, treatment can be titrated to the previously effective dose.

Other antipsychotic medications may be available depending on location.

Primary options

paliperidone: 6 mg orally once daily initially, increase gradually according to response, maximum 12 mg/day

OR

ziprasidone: 20 mg orally twice daily initially, increase gradually according to response, maximum 160 mg/day

OR

aripiprazole: 10-15 mg orally once daily initially, increase gradually according to response, maximum 30 mg/day

OR

risperidone: 1 mg orally twice daily initially, increase gradually according to response, maximum 16 mg/day (usual range 4-8 mg/day), doses >6 mg/day increase risk of extrapyramidal effects

OR

quetiapine: 25 mg orally (immediate release) twice daily initially, increase gradually according to response, maximum 800 mg/day; 300 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 800 mg/day

OR

iloperidone: 1 mg orally twice daily initially, increase gradually according to response, maximum 24 mg/day

OR

asenapine: 5 mg sublingually twice daily initially, increase gradually according to response, maximum 20 mg/day

OR

lurasidone: 40 mg orally once daily initially, increase gradually according to response, maximum 160 mg/day

OR

brexpiprazole: 1 mg orally once daily for 4 days, then 2 mg once daily for 3 days, then 4 mg once daily, maximum 4 mg/day

OR

cariprazine: 1.5 mg orally once daily on day 1, then 3 mg once daily on day 2, then increase gradually according to response, maximum 6 mg/day

OR

lumateperone: 42 mg orally once daily

Secondary options

olanzapine: 5-10 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day

More

OR

clozapine: 12.5 mg orally once or twice daily initially, increase gradually according to response, maximum 900 mg/day

More

Tertiary options

haloperidol: 0.5 to 5 mg orally two to three times daily initially, increase gradually according to response, usual dose 5-20 mg/day, maximum 100 mg/day

OR

fluphenazine: 2.5 to 10 mg/day orally given in 3-4 divided doses initially, increase gradually according to response, maximum 40 mg/day

OR

trifluoperazine: 1-2 mg orally twice daily initially, increase gradually according to response, maximum 40 mg/day

Consider – oral benzodiazepine

Back
ACUTE
|
acute psychotic episode
Consider – 

oral benzodiazepine

Treatment recommended for SOME patients in selected patient group

If the patient is severely agitated or distressed, consider an oral benzodiazepine, if tolerated.[72]

Primary options

lorazepam: 2 mg orally every 30-60 minutes when required

Consider – rapid tranquilization

Back
ACUTE
|
acute psychotic episode
Consider – 

rapid tranquilization

Treatment recommended for SOME patients in selected patient group

In cases of extreme agitation and violence, parenteral medication (rapid tranquilization) may be used if de-escalation techniques and oral benzodiazepines have failed, and only if absolutely necessary after weighing up the risks and benefits. Protocols for rapid tranquilization vary.

Intramuscular lorazepam alone is often used and is recommended in some guidelines.[33]

Haloperidol is used less often as it is associated with a risk of extrapyramidal side effects (e.g., dystonia). Cochrane systematic reviews have found that adding promethazine to haloperidol is supported by some evidence from randomized trials, but adding a benzodiazepine to other drugs is not supported by evidence, and increases the potential for adverse effects.[44][45]

The American Psychiatric Association guideline on the treatment of patients with schizophrenia also warns that while emergency administration of antipsychotic medication may be useful in individuals with acute agitation, it can also reduce tolerability and may contribute to a perception that premature dose increases are needed.[32]

Consult your local protocols for choice of drug regimen and dose.

Consider – electroconvulsive therapy

Back
ACUTE
|
acute psychotic episode
Consider – 

electroconvulsive therapy

Treatment recommended for SOME patients in selected patient group

Evidence suggests electroconvulsive therapy (ECT) is beneficial in patients with schizophrenia, particularly in patients with catatonia or significant suicide risk.[32] ECT is also effective for refractory major mood symptoms and may be considered for treatment-refractory schizoaffective disorder in conjunction with antipsychotic therapy. 

There are no clear studies demonstrating superiority of specific antipsychotics as augmentation with ECT. In studies of patients with schizophrenia, symptoms and rates of remission improved with clozapine plus ECT treatment compared with clozapine alone.[32][68] Some evidence suggests antipsychotics other than clozapine may also be beneficial.[32]

Other medications may need to be adjusted before starting ECT as some (e.g., benzodiazepines, lithium) can affect the treatment.[69] Consult a specialist for guidance.

ONGOING

multiple-episode disorder

1st line – atypical antipsychotic

Back
ONGOING
|
multiple-episode disorder
1st line – 

atypical antipsychotic

The first line of treatment should be an atypical antipsychotic agent other than clozapine.[47] The benefits of these agents over older antipsychotics in terms of decreased risk for extrapyramidal adverse effects and tardive dyskinesia need to be balanced on an individual basis against the increased risk for weight gain and metabolic syndrome, which is especially seen with olanzapine.[41]

For patients with established illness, information on previous treatments, dose, duration of treatment, and response to each particular agent should be gathered.

Patients should be given the minimum dose that controls their symptoms, with adequate follow-up for possible medication adjustments and monitoring of adverse effects. Medication should be continued indefinitely but titrated, switched to another agent, or discontinued if adverse effects are intolerable. There is no correlation between the drug dose and therapeutic effect, but the risk of extrapyramidal signs (e.g., akathisia, parkinsonism, and dystonia) increases with dose.

In people with treatment-responsive, multi-episode schizoaffective disorder who are experiencing an acute exacerbation, the minimum recommended length of treatment trial is 2 weeks, with an upper limit of 6 weeks to observe optimal response.

For maintenance therapy, continuous treatment is recommended. Intermittent, targeted treatment may increase the risk for symptom exacerbation and relapse, and it is not recommended.[47]

If the first agent that is used fails, a trial with a different atypical antipsychotic agent (other than clozapine) should be done.

Other antipsychotic medications may be available depending on location.

Primary options

paliperidone: 6 mg orally once daily initially, increase gradually according to response, maximum 12 mg/day

OR

olanzapine: 5-10 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day

More

OR

ziprasidone: 20 mg orally twice daily initially, increase gradually according to response, maximum 160 mg/day

OR

aripiprazole: 10-15 mg orally once daily initially, increase gradually according to response, maximum 30 mg/day

OR

risperidone: 1 mg orally twice daily initially, increase gradually according to response, maximum 16 mg/day (usual range 4-8 mg/day), doses >6 mg/day increase risk of extrapyramidal effects

OR

quetiapine: 25 mg orally (immediate release) twice daily initially, increase gradually according to response, maximum 800 mg/day; 300 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 800 mg/day

OR

iloperidone: 1 mg orally twice daily initially, increase gradually according to response, maximum 24 mg/day

OR

asenapine: 5 mg sublingually twice daily initially, increase gradually according to response, maximum 20 mg/day

OR

lurasidone: 40 mg orally once daily initially, increase gradually according to response, maximum 160 mg/day

OR

brexpiprazole: 1 mg orally once daily for 4 days, then 2 mg once daily for 3 days, then 4 mg once daily, maximum 4 mg/day

OR

cariprazine: 1.5 mg orally once daily on day 1, then 3 mg once daily on day 2, then increase gradually according to response, maximum 6 mg/day

OR

lumateperone: 42 mg orally once daily

Plus – psychosocial interventions

Back
ONGOING
|
multiple-episode disorder
Plus – 

psychosocial interventions

Treatment recommended for ALL patients in selected patient group

Psychosocial interventions are key components of long-term management. The Patient Outcomes Research Team (PORT) guidelines recommend the following psychosocial interventions: assertive community treatment, supported employment, skills training, cognitive behavioral therapy (CBT), token economy interventions, and family-based services.[47] [ Cochrane Clinical Answers logo ]  CBT for psychosis (CBTp), cognitive remediation, psychoeducation, and supportive therapy have been shown to be effective and should be started early in treatment.[32][47][56] Other interventions that may be beneficial include supportive psychotherapy, intensive case management, and cognitive enhancement treatment.[32]

CBTp is more efficacious in decreasing positive symptoms, and social skill training is efficacious in decreasing negative symptoms.[57][58]

A minimum duration of 16 CBTp sessions is recommended.[32][59] However, studies suggest that treatment benefits may no longer be significant after 6 months.

Monitor for depressive symptoms and risk factors for suicide. Case management should be implemented early in the illness process.

Family issues need to be addressed early because interventions are useful in relapse prevention.

Plus – general health maintenance

Back
ONGOING
|
multiple-episode disorder
Plus – 

general health maintenance

Treatment recommended for ALL patients in selected patient group

Schizoaffective disorder is associated with increased frequency of medical illnesses and with a 15- to 20-year reduction in life expectancy. Managing the adverse effects of medications is crucial because many of these agents further increase the risk of medical illness. Health maintenance is, therefore, targeted to these adverse effects.

Possible adverse effects include neurologic adverse effects, metabolic abnormalities (weight gain, blood glucose levels), hyperprolactinemia, cardiac abnormalities, agranulocytosis, postural hypotension, and anticholinergic adverse effects.

Consider – anxiolytic

Back
ONGOING
|
multiple-episode disorder
Consider – 

anxiolytic

Treatment recommended for SOME patients in selected patient group

Patients with symptoms of anxiety may benefit from the addition of an anxiolytic.[53]

Studies have failed to demonstrate that buspirone is consistently effective against panic attacks.[54][55]

Primary options

alprazolam: 0.25 mg orally (immediate-release) three times daily initially, increase gradually according to response, maximum 4 mg/day

OR

clonazepam: 0.25 mg orally twice daily initially, increase gradually according to response, maximum 4 mg/day

OR

diazepam: 2-10 mg orally two to four times daily

OR

buspirone: 7.5 mg orally twice daily initially, increase gradually according to response, maximum 60 mg/day

Consider – lithium

Back
ONGOING
|
multiple-episode disorder
Consider – 

lithium

Treatment recommended for SOME patients in selected patient group

For patients who do not achieve a satisfactory treatment response with antipsychotics, augmentation with lithium may improve the clinical response.[51]

Primary options

lithium: 300 mg orally (regular-release) two to three times daily initially, increase gradually according to response and serum drug level, maximum 2400 mg/day

2nd line – clozapine for treatment failure of 2 preferred atypical antipsychotic agents

Back
ONGOING
|
multiple-episode disorder
2nd line – 

clozapine for treatment failure of 2 preferred atypical antipsychotic agents

Clozapine may be recommended for patients with multiple episode disorder who fail at least two adequate trials of two different antipsychotic agents.

A trial of clozapine should last a minimum of 8 weeks.[47]

Routine checking of serum clozapine levels is not recommended; however, for clozapine non-responders it is recommended that the dose be increased, adverse effects permitting, for a target level >350 nanograms/mL.

Clozapine is available only under a restricted access scheme in the US and many other countries. White blood cell count and absolute neutrophil count should be tested periodically, owing to the risk of potentially life-threatening agranulocytosis.

Primary options

clozapine: 12.5 mg orally once or twice daily initially, increase gradually according to response, maximum 900 mg/day

Plus – psychosocial interventions

Back
ONGOING
|
multiple-episode disorder
Plus – 

psychosocial interventions

Treatment recommended for ALL patients in selected patient group

Psychosocial interventions are key components of long-term management. The Patient Outcomes Research Team (PORT) guidelines recommend the following psychosocial interventions: assertive community treatment, supported employment, skills training, cognitive behavioral therapy (CBT), token economy interventions, and family-based services.[47] [ Cochrane Clinical Answers logo ]  CBT for psychosis (CBTp), cognitive remediation, psychoeducation, and supportive therapy have been shown to be effective and should be started early in treatment.[32][47][56] Other interventions that may be beneficial include supportive psychotherapy, intensive case management, and cognitive enhancement treatment.[32]

CBTp is more efficacious in decreasing positive symptoms, and social skill training is efficacious in decreasing negative symptoms.[57][58]

A minimum duration of 16 CBTp sessions is recommended.[32][59] However, studies suggest that treatment benefits may no longer be significant after 6 months.

Monitor for depressive symptoms and risk factors for suicide. Case management should be implemented early in the illness process.

Family issues need to be addressed early because interventions are useful in relapse prevention.

Plus – general health maintenance

Back
ONGOING
|
multiple-episode disorder
Plus – 

general health maintenance

Treatment recommended for ALL patients in selected patient group

Schizoaffective disorder is associated with increased frequency of medical illnesses and with a 15- to 20-year reduction in life expectancy. Managing the adverse effects of medications is crucial because many of these agents further increase the risk of medical illness. Health maintenance is, therefore, targeted to these adverse effects.

Possible adverse effects include neurologic adverse effects, metabolic abnormalities (weight gain, blood glucose levels), hyperprolactinemia, cardiac abnormalities, agranulocytosis, postural hypotension, and anticholinergic adverse effects.

Consider – anxiolytic

Back
ONGOING
|
multiple-episode disorder
Consider – 

anxiolytic

Treatment recommended for SOME patients in selected patient group

Patients with symptoms of anxiety may benefit from the addition of an anxiolytic.[53]

Studies have failed to demonstrate that buspirone is consistently effective against panic attacks.[54][55]

Primary options

alprazolam: 0.25 mg orally (immediate-release) three times daily initially, increase gradually according to response, maximum 4 mg/day

OR

clonazepam: 0.25 mg orally twice daily initially, increase gradually according to response, maximum 4 mg/day

OR

diazepam: 2-10 mg orally two to four times daily

OR

buspirone: 7.5 mg orally twice daily initially, increase gradually according to response, maximum 60 mg/day

Consider – lithium

Back
ONGOING
|
multiple-episode disorder
Consider – 

lithium

Treatment recommended for SOME patients in selected patient group

For patients who do not achieve a satisfactory treatment response with antipsychotics, augmentation with lithium may improve the clinical response.[51]

Primary options

lithium: 300 mg orally (regular-release) two to three times daily initially, increase gradually according to response and serum drug level, maximum 2400 mg/day

3rd line – typical antipsychotic

Back
ONGOING
|
multiple-episode disorder
3rd line – 

typical antipsychotic

The efficacy of these medications is well established, but they are not generally recommended as initial treatment because they carry a higher likelihood of tardive dyskinesia and worsening of negative symptoms.

Haloperidol use should be limited to situations when no other antipsychotic medications with fewer extrapyramidal adverse effects can be used.

In pregnancy, typical antipsychotics appear less harmful than atypical antipsychotics in terms of risk of gestational metabolic complications, increased weight for gestational age, and birth weight.

Medication should be continued indefinitely, but should be titrated, switched to another agent, or discontinued if adverse effects are intolerable.

Other antipsychotic medications may be available depending on location.

Primary options

haloperidol: 0.5 to 5 mg orally two to three times daily initially, increase gradually according to response, usual dose 5-20 mg/day, maximum 100 mg/day

OR

fluphenazine: 2.5 to 10 mg/day orally given in 3-4 divided doses initially, increase gradually according to response, maximum 40 mg/day

OR

trifluoperazine: 1-2 mg orally twice daily initially, increase gradually according to response, maximum 40 mg/day

Plus – psychosocial interventions

Back
ONGOING
|
multiple-episode disorder
Plus – 

psychosocial interventions

Treatment recommended for ALL patients in selected patient group

Psychosocial interventions are key components of long-term management. The Patient Outcomes Research Team (PORT) guidelines recommend the following psychosocial interventions: assertive community treatment, supported employment, skills training, cognitive behavioral therapy (CBT), token economy interventions, and family-based services.[47] [ Cochrane Clinical Answers logo ]  CBT for psychosis (CBTp), cognitive remediation, psychoeducation, and supportive therapy have been shown to be effective and should be started early in treatment.[32][47][56] Other interventions that may be beneficial include supportive psychotherapy, intensive case management, and cognitive enhancement treatment.[32]

CBTp is more efficacious in decreasing positive symptoms, and social skill training is efficacious in decreasing negative symptoms.[57][58]

A minimum duration of 16 CBTp sessions is recommended.[32][59] However, studies suggest that treatment benefits may no longer be significant after 6 months.

Monitor for depressive symptoms and risk factors for suicide. Case management should be implemented early in the illness process.

Family issues need to be addressed early because interventions are useful in relapse prevention.

Plus – general health maintenance

Back
ONGOING
|
multiple-episode disorder
Plus – 

general health maintenance

Treatment recommended for ALL patients in selected patient group

Schizoaffective disorder is associated with increased frequency of medical illnesses and with a 15- to 20-year reduction in life expectancy. Managing the adverse effects of medications is crucial because many of these agents further increase the risk of medical illness. Health maintenance is, therefore, targeted to these adverse effects.

Possible adverse effects include neurologic adverse effects, metabolic abnormalities (weight gain, blood glucose levels), hyperprolactinemia, cardiac abnormalities, agranulocytosis, postural hypotension, and anticholinergic adverse effects.

Consider – anxiolytic

Back
ONGOING
|
multiple-episode disorder
Consider – 

anxiolytic

Treatment recommended for SOME patients in selected patient group

Patients with symptoms of anxiety may benefit from the addition of an anxiolytic.[53]

Studies have failed to demonstrate that buspirone is consistently effective against panic attacks.[54][55]

Primary options

alprazolam: 0.25 mg orally (immediate-release) three times daily initially, increase gradually according to response, maximum 4 mg/day

OR

clonazepam: 0.25 mg orally twice daily initially, increase gradually according to response, maximum 4 mg/day

OR

diazepam: 2-10 mg orally two to four times daily

OR

buspirone: 7.5 mg orally twice daily initially, increase gradually according to response, maximum 60 mg/day

Consider – lithium

Back
ONGOING
|
multiple-episode disorder
Consider – 

lithium

Treatment recommended for SOME patients in selected patient group

For patients who do not achieve a satisfactory treatment response with antipsychotics, augmentation with lithium may improve the clinical response.[51]

Primary options

lithium: 300 mg orally (regular-release) two to three times daily initially, increase gradually according to response and serum drug level, maximum 2400 mg/day

4th line – long-acting intramuscular antipsychotic

Back
ONGOING
|
multiple-episode disorder
4th line – 

long-acting intramuscular antipsychotic

In patients with an extensive history of noncompliance, a long-acting intramuscular antipsychotic should be considered. Oral efficacy and tolerability should be established first before switching to an long-acting intramuscular antipsychotic.[43]

Depot fluphenazine may have similar efficacy as oral fluphenazine in treating patients with schizophrenia.[73]

Primary options

risperidone: 25-50 mg intramuscularly (extended-release suspension) every 2 weeks

OR

paliperidone: 234 mg intramuscularly (extended-release suspension) as a single dose initially, followed by 156 mg one week later, then 117 mg once monthly thereafter

OR

olanzapine: 150-300 mg intramuscularly (extended-release suspension) every 2 weeks, or 405 mg every 2 weeks

OR

aripiprazole: 300-400 mg intramuscularly once monthly

More

Secondary options

haloperidol decanoate: dose depends on previous oral haloperidol dose; consult specialist for guidance

OR

fluphenazine decanoate: 12.5 to 25 mg intramuscularly once monthly or at longer intervals depending on response and tolerance

Plus – psychosocial interventions

Back
ONGOING
|
multiple-episode disorder
Plus – 

psychosocial interventions

Treatment recommended for ALL patients in selected patient group

Psychosocial interventions are key components of long-term management. The Patient Outcomes Research Team (PORT) guidelines recommend the following psychosocial interventions: assertive community treatment, supported employment, skills training, cognitive behavioral therapy (CBT), token economy interventions, and family-based services.[47] [ Cochrane Clinical Answers logo ]  CBT for psychosis (CBTp), cognitive remediation, psychoeducation, and supportive therapy have been shown to be effective and should be started early in treatment.[32][47][56] Other interventions that may be beneficial include supportive psychotherapy, intensive case management, and cognitive enhancement treatment.[32]

CBTp is more efficacious in decreasing positive symptoms, and social skill training is efficacious in decreasing negative symptoms.[57][58]

A minimum duration of 16 CBTp sessions is recommended.[32][59] However, studies suggest that treatment benefits may no longer be significant after 6 months.

Monitor for depressive symptoms and risk factors for suicide. Case management should be implemented early in the illness process.

Family issues need to be addressed early because family are useful in relapse prevention.

Plus – general health maintenance

Back
ONGOING
|
multiple-episode disorder
Plus – 

general health maintenance

Treatment recommended for ALL patients in selected patient group

Schizoaffective disorder is associated with increased frequency of medical illnesses and with a 15- to 20-year reduction in life expectancy. Managing the adverse effects of medications is crucial because many of these agents further increase the risk of medical illness. Health maintenance is, therefore, targeted to these adverse effects.

Possible adverse effects include neurologic adverse effects, metabolic abnormalities (weight gain, blood glucose levels), hyperprolactinemia, cardiac abnormalities, agranulocytosis, postural hypotension, and anticholinergic adverse effects.

Consider – anxiolytic

Back
ONGOING
|
multiple-episode disorder
Consider – 

anxiolytic

Treatment recommended for SOME patients in selected patient group

Patients with symptoms of anxiety may benefit from the addition of an anxiolytic.[53]

Studies have failed to demonstrate that buspirone is consistently effective against panic attacks.[54][55]

Primary options

alprazolam: 0.25 mg orally (immediate-release) three times daily initially, increase gradually according to response, maximum 4 mg/day

OR

clonazepam: 0.25 mg orally twice daily initially, increase gradually according to response, maximum 4 mg/day

OR

diazepam: 2-10 mg orally two to four times daily

OR

buspirone: 7.5 mg orally twice daily initially, increase gradually according to response, maximum 60 mg/day

Consider – lithium

Back
ONGOING
|
multiple-episode disorder
Consider – 

lithium

Treatment recommended for SOME patients in selected patient group

For patients who do not achieve a satisfactory treatment response with antipsychotics, augmentation with lithium may improve the clinical response.[51]

Primary options

lithium: 300 mg orally (regular-release) two to three times daily initially, increase gradually according to response and serum drug level, maximum 2400 mg/day

5th line – electroconvulsive therapy

Back
ONGOING
|
multiple-episode disorder
5th line – 

electroconvulsive therapy

Evidence suggests electroconvulsive therapy (ECT) is beneficial in patients with schizophrenia, particularly in patients with catatonia or significant suicide risk.[32] ECT is also effective for refractory major mood symptoms and may be considered for treatment-refractory schizoaffective disorder in conjunction with antipsychotic therapy.

Plus – clozapine or other antipsychotic therapy

Back
ONGOING
|
multiple-episode disorder
Plus – 

clozapine or other antipsychotic therapy

Treatment recommended for ALL patients in selected patient group

There are no clear studies demonstrating superiority of specific antipsychotics as augmentation with electroconvulsive therapy (ECT).

In studies of patients with schizophrenia, symptoms and rates of remission improved with clozapine plus ECT treatment compared with clozapine alone.[32][68] Some evidence suggests antipsychotics other than clozapine may also be beneficial.[32]

Consult a specialist for guidance on antipsychotic selection and dose.

Plus – psychosocial interventions

Back
ONGOING
|
multiple-episode disorder
Plus – 

psychosocial interventions

Treatment recommended for ALL patients in selected patient group

Psychosocial interventions are key components of long-term management. The Patient Outcomes Research Team (PORT) guidelines recommend the following psychosocial interventions: assertive community treatment, supported employment, skills training, cognitive behavioral therapy (CBT), token economy interventions, and family-based services.[47] [ Cochrane Clinical Answers logo ]  CBT for psychosis (CBTp), cognitive remediation, psychoeducation, and supportive therapy have been shown to be effective and should be started early in treatment.[32][47][56] Other interventions that may be beneficial include supportive psychotherapy, intensive case management, and cognitive enhancement treatment.[32]

CBTp is more efficacious in decreasing positive symptoms, and social skill training is efficacious in decreasing negative symptoms.[57][58]

A minimum duration of 16 CBTp sessions is recommended.[32][59] However, studies suggest that treatment benefits may no longer be significant after 6 months.

Monitor for depressive symptoms and risk factors for suicide. Case management should be implemented early in the illness process.

Family issues need to be addressed early because family are useful in relapse prevention.

Plus – general health maintenance

Back
ONGOING
|
multiple-episode disorder
Plus – 

general health maintenance

Treatment recommended for ALL patients in selected patient group

Schizoaffective disorder is associated with increased frequency of medical illnesses and with a 15- to 20-year reduction in life expectancy. Managing the adverse effects of medications is crucial because many of these agents further increase the risk of medical illness. Health maintenance is, therefore, targeted to these adverse effects.

Possible adverse effects include neurologic adverse effects, metabolic abnormalities (weight gain, blood glucose levels), hyperprolactinemia, cardiac abnormalities, agranulocytosis, postural hypotension, and anticholinergic adverse effects.

Plus – antidepressant

Back
ONGOING
|
multiple-episode disorder
|
with depressive symptoms
Plus – 

antidepressant

Treatment recommended for ALL patients in selected patient group

An antidepressant can be added to antipsychotic medication for patients who have symptoms of depression associated with the illness. Antidepressants should be prescribed conservatively, mostly during the course of a depressive episode, in order to avoid a precipitation of a manic or mixed episode.

Primary options

fluoxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

OR

paroxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 50 mg/day

OR

citalopram: 20 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day

OR

sertraline: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

OR

mirtazapine: 15 mg orally once daily initially, increase gradually according to response, maximum 45 mg/day

Plus – mood stabilizer

Back
ONGOING
|
multiple-episode disorder
|
with manic or mixed manic-depressive symptoms
Plus – 

mood stabilizer

Treatment recommended for ALL patients in selected patient group

A mood stabilizer can be added to antipsychotic medication for manic or mixed symptoms associated with the illness.

Serum drug levels should be monitored - therapeutic levels can vary between laboratories.

In the US, standard practice is that valproate and its analogs are only prescribed for the treatment of manic episodes associated with bipolar disorder or schizoaffective disorder during pregnancy if other alternative medications are not acceptable or not effective. In 2018, the European Medicines Agency (EMA) recommended that valproate and its analogs are contraindicated in bipolar disorder during pregnancy due to the risk of congenital malformations and developmental problems in the infant/child.[52] The EMA did not comment specifically on use of valproate during pregnancy in schizoaffective disorder, but it is reasonable to extrapolate that this is also contraindicated. In both Europe and the US, valproate and its analogs must not be used in female patients of childbearing potential unless there is a pregnancy prevention program in place and certain conditions are met.[52]

Primary options

lithium: 300 mg orally (regular-release) two to three times daily initially, increase gradually according to response and serum drug level, maximum 2400 mg/day

OR

carbamazepine: 200 mg orally (extended-release) twice daily initially, increase gradually according to response and serum drug level, maximum 1600 mg/day

OR

divalproex sodium: 250 mg orally (delayed-release) three times daily initially, increase gradually according to response and serum drug level, maximum 60 mg/kg/day; 25 mg/kg orally (extended-release) once daily initially, increase gradually according to response and serum drug level, maximum 60 mg/kg/day

OR

lamotrigine: dose may depend on what drugs a patient is currently on; consult specialist for guidance on dose

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer